CASE REPORTS
A transnasal fiberoptic bronchoscopy was done to obtain tracheobronchial secretions for examination. This was carried out after the pneumomediastinum was recognized but before the pneumothorax developed. No brushings or biopsies were done. The procedure was tolerated with little coughing. We are unable to exclude the bronchoscopy as contributing toward development of the pneumothorax but the symptoms of sudden shortness of breath did not occur until several hours after the procedure. The finding of mouth organisms in the culture of the TTA specimen probably indicates that the tip of the catheter was coughed into the pharyngeal area during the procedure. The authors do not want to defend the use of TTA or fiberoptic bronchoscopy in the management of this case. It should be noted, however, that at the time the procedures were done the diagnosis of fat embolism was not established. Although TTA is recognized as a valuable diagnostic procedure in lower respiratory tract infections, it is not without complications. Where pneumomediastinum is present following transtracheal aspiration, clinical deterioration or sudden shortness of breath should alert clinicians to the possibility of pneumothorax. Transtracheal aspiration should be included as another potential iatrogenic cause of pneumothorax.7
Summary In a patient with pulmonary insufficiency secondary to fat embolism, pneumomediastinum, pneumopericardium and bilateral pneumothorax developed following a transtracheal aspiration. Air dissection down the paratracheal fascial plane with rupture into the pleural spaces bilaterally is the proposed pathogenic mechanism for this unique complication. REFERENCES 1. Pecora DV: A method for securing uncontaminated tracheal secretions for bacterial examination. J Thor Cardiovasc Surg 37: 653b654, 1959 2. Kalinske RW, Parker RH, Brandt D, et al: Diagnostic usefulness and safety of transtracheal aspiration. N Engl J Med 276: 604.608, Mar 16, 1967 3. Hahn HH, Beaty HN: Transtracheal aspiration in the evaluation of patients with pneumonia. Ann Intern Med 72:183-187, Feb 1970 4. Spencer CD, Beaty HN: Complications of transtracheal aspiration. N Engl J Med 286:304-306, Feb 10, 1972 5. Rabuzzi DD, Reed GF: Intrathoracic complications following tracheotomy in children. Tran Am Laryngol Rhinol Otol Soc 74: 71-79, 1971 6. Padovan IF, Dawson CA, Henschel EO, et al: Pathogenesis of mediastinal emphysema and pneumothorax following tracheotomy. Chest 66:553-556, 1974 7. Steier M, Ching N, Bonfils-Roberts E, et al: Iatrogenic causes of pneumothorax. NY State J Med 73:1296-1298, Jun 1973
Refer to: Blonde L, Witkin M, Harris R: Painless subacute thyroiditis simulating Graves' disease. West J Med 125: 75-78, Jul 1976
Painless Subacute Thyroiditis Simulating Graves' Disease LAWRENCE BLONDE, MD MICHAEL WITKIN, MD RONALD HARRIS, MD New Orleans SUBACUTE THYROIDITIS (DeQuervain's thyroiditis) usually begins with painful, tender thyromegaly, evidence of hypermetabolism and nonspecific symptoms such as fever, malaise, myalgias and arthralgias.1 Subacute thyroiditis without pain or tenderness is described in surgical reports2-4 but not emphasized in medical series.",5-8 This report describes four cases, collected over two years, of painless subacute thyroiditis with initial symptoms and signs like those of hyperthyroidism. In all four patients (three female and 1 male), painless thyroid enlargement, clinical hyperthyroidism, elevated serum thyroxine levels, normal or only slightly elevated sedimentation rates and suppressed thyroidal uptake of radioactive iodine were present initially (Table 1). None of these patients had ingested exogenous thyroid hormone, iodides or other medications. During subsequent observation, the goiters and laboratory abnormalities disappeared and the patients became clinically euthyroid with only symptomatic support.
Reports of Cases CASE 1. A 19-year-old white male college student with no spontaneous complaints was seen for a preemployment physical examination. On examination, the thyroid gland was found to be enlarged to three times normal size and was firm but not tender. Findings from the physical examination were otherwise normal. Subsequent quesFrom the Department of Internal Medicine, Section on Endocrinology and Metabolic Disease, Alton Ochsner Medical Foundation and Ochsner Clinic, New Orleans (Drs. Blonde, Witkin and Harris); and the Endocrinology/Nuclear Medicine Service, Martin Army Hospital, Ft. Benning, Georgia (Dr. Blonde). Submitted July 28, 1975. Reprint requests to: Lawrence Blonde, MD, Ochsner Clinic, 1514 Jefferson Highway, New Orleans, LA 70121.
THE WESTERN JOURNAL OF MEDICINE
75
CASE REPORTS
tioning revealed a one month history of nervousness, heat intolerance, insomnia and a 5 kg weight loss, despite a good appetite. A complete blood count was within normal limits with an erythrocyte sedimentation rate of 8 mm per hour (Westergren, normal for men is 0 to 10). Serum thyroxine by competitive protein binding was 14.3 ,tg per dl (normal 4 to 11 jug per dl). Resin T-3 uptake was 70 percent (normal 40 to 60 percent). The patient was thought to have Graves' disease until the uptake of radioactive iodine (1311) was found to be less than 2 percent at 24 hours (normal 10 to 30 percent). Treatment was deferred. Over the next four weeks the patient reported spontaneous clinical improvement but subsequently complained of fatigue, at which time a repeat test of serum thyroxine was found to be less than 1 ,Wg per dl and administration of sodium levothyroxine (Synthroid®), 0.2 mg per day, was begun. Three months later, while still taking the medication, the T-4 and resin T-3 uptake were within normal limits. Thyromegaly had disappeared and the patient felt well. Administration of levothyroxine was discontinued. The patient was restudied two months later and was found to be euthyroid. CASE 2. A 22-year-old white woman came to the emergency room because of palpitations and heat intolerance. During the preceding three weeks the patient had experienced nervousness, irritability, insomnia, heat intolerance and a 2.3 kg weight loss, despite good appetite. The patient said that there had been no neck pain. The pulse was 110 beats per minute, blood pressure 140/70 mm of mercury. The skin was warm and moist to the touch. A fine tremor of the outstretched hands and lid lag were noted, but no other eye signs of Graves' disease. The thyroid gland was found to be enlarged to about 60 grams in size. It was firm in consistency and not tender. The remainder of the examination gave findings within normal limits.
Case Number
Age (years)
1. 2. 3. 4
..
.
19 22 24 13½
TABLE 1.-Case Summaries-Painless Subacute Thyroiditis Initial 24hr Sex
Goiter
ESR *
M
3X 3X 2X
8 22 15 6
F F F
3X
*Erythrocyte sedimentation rate: Normal male = 0-10 mm/hr; Normal female=0-20 mm/hr.
76
The T-4 was 12.5 jug per dl with a resin T-3 uptake of 65 percent. Findings on complete blood count, Sequential Multiple Analysis (SMA) 12/60 and urinalysis were all within normal limits. Erythrocyte sedimentation rate was 22 mm per hour (Westergren, normal for women is 0 to 20). The uptake of radioactive iodine was less than 2 percent at 6 and 24 hours after administration. Titers of antimicrosomal and antithyroglobulin antibodies (Bio-Science) were within normal limits. Over the next three weeks there was some regression of the thyromegaly. Serum thyroxine values fell to normal limits after three weeks and to less than 1 ptg per dl after six weeks. At this time sodium levothyroxine (0.15 mg per day) was prescribed which resulted in the serum thyroxine value returning to within normal limits. Administration of the medication was discontinued after three months and the patient has remained euthyroid. CASE 3. A 24-year-old white, married woman was evaluated for heat intolerance of six weeks duration, weight loss of 4.5 kg despite good appetite, and thyromegaly without associated pain. The pulse was 120 beats per minute and blood pressure 130/60 mm of mercury. There were no eye signs of thyroid disease. The skin was warm and moist. There was a fine tremor present. The thyroid gland was enlarged to about twice the normal size and was firm but not tender. The T-4 was 13.5 jug per dl; resin T-3 uptake, 63 percent. Uptake of radioactive iodine was 2 percent at both 6 and 24 hours. Complete blood count was within normal limits, with an erythrocyte sedimentation rate of 15 mm per hour (Westergren). Tests gave negative findings for antithyroglobulin and antimicrosomal antibodies. The patient was given propranolol (InderalP), 20 mg four times a day, but no other medications. Over the next eight weeks the thyroid gland returned to normal size, administration of propranolol was discontinued and the patient be-
JULY 1976 * 125 * 1
13'1 Uptaket
Initial Serum
2 2 2 2
12.5
(percent)
t Normal = 10-30%. $Normal = 4-11 jug/dl.
T-4$
Final Uptake (percent)
14.3 13.5 15.6
27
Final T-4
8.0 7.5 8.4 6.4
CASE REPORTS
TABLE 2.-Association of Pain with Subacute Thyroiditis Previous Reports
Pain
Aledical Schultz5 ............. 24 Volpe et al6 .......... 52 Vanderlinde et at7 13 Saito8 ............... 49 Surgical Woolner et al2 ....... 21 Stein et at3 .......... 23 Harland and Frantz4 . ..
A transnasal fiberoptic bronchoscopy was done to obtain tracheobronchial secretions for examination. This was carried out after the pneumomediastinum was recognized but before the pneumothorax developed. No brushings or biopsies were done. The procedure was tolerated with little coughing. We are unable to exclude the bronchoscopy as contributing toward development of the pneumothorax but the symptoms of sudden shortness of breath did not occur until several hours after the procedure. The finding of mouth organisms in the culture of the TTA specimen probably indicates that the tip of the catheter was coughed into the pharyngeal area during the procedure. The authors do not want to defend the use of TTA or fiberoptic bronchoscopy in the management of this case. It should be noted, however, that at the time the procedures were done the diagnosis of fat embolism was not established. Although TTA is recognized as a valuable diagnostic procedure in lower respiratory tract infections, it is not without complications. Where pneumomediastinum is present following transtracheal aspiration, clinical deterioration or sudden shortness of breath should alert clinicians to the possibility of pneumothorax. Transtracheal aspiration should be included as another potential iatrogenic cause of pneumothorax.7
Summary In a patient with pulmonary insufficiency secondary to fat embolism, pneumomediastinum, pneumopericardium and bilateral pneumothorax developed following a transtracheal aspiration. Air dissection down the paratracheal fascial plane with rupture into the pleural spaces bilaterally is the proposed pathogenic mechanism for this unique complication. REFERENCES 1. Pecora DV: A method for securing uncontaminated tracheal secretions for bacterial examination. J Thor Cardiovasc Surg 37: 653b654, 1959 2. Kalinske RW, Parker RH, Brandt D, et al: Diagnostic usefulness and safety of transtracheal aspiration. N Engl J Med 276: 604.608, Mar 16, 1967 3. Hahn HH, Beaty HN: Transtracheal aspiration in the evaluation of patients with pneumonia. Ann Intern Med 72:183-187, Feb 1970 4. Spencer CD, Beaty HN: Complications of transtracheal aspiration. N Engl J Med 286:304-306, Feb 10, 1972 5. Rabuzzi DD, Reed GF: Intrathoracic complications following tracheotomy in children. Tran Am Laryngol Rhinol Otol Soc 74: 71-79, 1971 6. Padovan IF, Dawson CA, Henschel EO, et al: Pathogenesis of mediastinal emphysema and pneumothorax following tracheotomy. Chest 66:553-556, 1974 7. Steier M, Ching N, Bonfils-Roberts E, et al: Iatrogenic causes of pneumothorax. NY State J Med 73:1296-1298, Jun 1973
Refer to: Blonde L, Witkin M, Harris R: Painless subacute thyroiditis simulating Graves' disease. West J Med 125: 75-78, Jul 1976
Painless Subacute Thyroiditis Simulating Graves' Disease LAWRENCE BLONDE, MD MICHAEL WITKIN, MD RONALD HARRIS, MD New Orleans SUBACUTE THYROIDITIS (DeQuervain's thyroiditis) usually begins with painful, tender thyromegaly, evidence of hypermetabolism and nonspecific symptoms such as fever, malaise, myalgias and arthralgias.1 Subacute thyroiditis without pain or tenderness is described in surgical reports2-4 but not emphasized in medical series.",5-8 This report describes four cases, collected over two years, of painless subacute thyroiditis with initial symptoms and signs like those of hyperthyroidism. In all four patients (three female and 1 male), painless thyroid enlargement, clinical hyperthyroidism, elevated serum thyroxine levels, normal or only slightly elevated sedimentation rates and suppressed thyroidal uptake of radioactive iodine were present initially (Table 1). None of these patients had ingested exogenous thyroid hormone, iodides or other medications. During subsequent observation, the goiters and laboratory abnormalities disappeared and the patients became clinically euthyroid with only symptomatic support.
Reports of Cases CASE 1. A 19-year-old white male college student with no spontaneous complaints was seen for a preemployment physical examination. On examination, the thyroid gland was found to be enlarged to three times normal size and was firm but not tender. Findings from the physical examination were otherwise normal. Subsequent quesFrom the Department of Internal Medicine, Section on Endocrinology and Metabolic Disease, Alton Ochsner Medical Foundation and Ochsner Clinic, New Orleans (Drs. Blonde, Witkin and Harris); and the Endocrinology/Nuclear Medicine Service, Martin Army Hospital, Ft. Benning, Georgia (Dr. Blonde). Submitted July 28, 1975. Reprint requests to: Lawrence Blonde, MD, Ochsner Clinic, 1514 Jefferson Highway, New Orleans, LA 70121.
THE WESTERN JOURNAL OF MEDICINE
75
CASE REPORTS
tioning revealed a one month history of nervousness, heat intolerance, insomnia and a 5 kg weight loss, despite a good appetite. A complete blood count was within normal limits with an erythrocyte sedimentation rate of 8 mm per hour (Westergren, normal for men is 0 to 10). Serum thyroxine by competitive protein binding was 14.3 ,tg per dl (normal 4 to 11 jug per dl). Resin T-3 uptake was 70 percent (normal 40 to 60 percent). The patient was thought to have Graves' disease until the uptake of radioactive iodine (1311) was found to be less than 2 percent at 24 hours (normal 10 to 30 percent). Treatment was deferred. Over the next four weeks the patient reported spontaneous clinical improvement but subsequently complained of fatigue, at which time a repeat test of serum thyroxine was found to be less than 1 ,Wg per dl and administration of sodium levothyroxine (Synthroid®), 0.2 mg per day, was begun. Three months later, while still taking the medication, the T-4 and resin T-3 uptake were within normal limits. Thyromegaly had disappeared and the patient felt well. Administration of levothyroxine was discontinued. The patient was restudied two months later and was found to be euthyroid. CASE 2. A 22-year-old white woman came to the emergency room because of palpitations and heat intolerance. During the preceding three weeks the patient had experienced nervousness, irritability, insomnia, heat intolerance and a 2.3 kg weight loss, despite good appetite. The patient said that there had been no neck pain. The pulse was 110 beats per minute, blood pressure 140/70 mm of mercury. The skin was warm and moist to the touch. A fine tremor of the outstretched hands and lid lag were noted, but no other eye signs of Graves' disease. The thyroid gland was found to be enlarged to about 60 grams in size. It was firm in consistency and not tender. The remainder of the examination gave findings within normal limits.
Case Number
Age (years)
1. 2. 3. 4
..
.
19 22 24 13½
TABLE 1.-Case Summaries-Painless Subacute Thyroiditis Initial 24hr Sex
Goiter
ESR *
M
3X 3X 2X
8 22 15 6
F F F
3X
*Erythrocyte sedimentation rate: Normal male = 0-10 mm/hr; Normal female=0-20 mm/hr.
76
The T-4 was 12.5 jug per dl with a resin T-3 uptake of 65 percent. Findings on complete blood count, Sequential Multiple Analysis (SMA) 12/60 and urinalysis were all within normal limits. Erythrocyte sedimentation rate was 22 mm per hour (Westergren, normal for women is 0 to 20). The uptake of radioactive iodine was less than 2 percent at 6 and 24 hours after administration. Titers of antimicrosomal and antithyroglobulin antibodies (Bio-Science) were within normal limits. Over the next three weeks there was some regression of the thyromegaly. Serum thyroxine values fell to normal limits after three weeks and to less than 1 ptg per dl after six weeks. At this time sodium levothyroxine (0.15 mg per day) was prescribed which resulted in the serum thyroxine value returning to within normal limits. Administration of the medication was discontinued after three months and the patient has remained euthyroid. CASE 3. A 24-year-old white, married woman was evaluated for heat intolerance of six weeks duration, weight loss of 4.5 kg despite good appetite, and thyromegaly without associated pain. The pulse was 120 beats per minute and blood pressure 130/60 mm of mercury. There were no eye signs of thyroid disease. The skin was warm and moist. There was a fine tremor present. The thyroid gland was enlarged to about twice the normal size and was firm but not tender. The T-4 was 13.5 jug per dl; resin T-3 uptake, 63 percent. Uptake of radioactive iodine was 2 percent at both 6 and 24 hours. Complete blood count was within normal limits, with an erythrocyte sedimentation rate of 15 mm per hour (Westergren). Tests gave negative findings for antithyroglobulin and antimicrosomal antibodies. The patient was given propranolol (InderalP), 20 mg four times a day, but no other medications. Over the next eight weeks the thyroid gland returned to normal size, administration of propranolol was discontinued and the patient be-
JULY 1976 * 125 * 1
13'1 Uptaket
Initial Serum
2 2 2 2
12.5
(percent)
t Normal = 10-30%. $Normal = 4-11 jug/dl.
T-4$
Final Uptake (percent)
14.3 13.5 15.6
27
Final T-4
8.0 7.5 8.4 6.4
CASE REPORTS
TABLE 2.-Association of Pain with Subacute Thyroiditis Previous Reports
Pain
Aledical Schultz5 ............. 24 Volpe et al6 .......... 52 Vanderlinde et at7 13 Saito8 ............... 49 Surgical Woolner et al2 ....... 21 Stein et at3 .......... 23 Harland and Frantz4 . ..
